Despite the rising number of monkeypox cases worldwide, the World Health Organization (WHO) has so far decided against calling the outbreak an international public health emergency—instead describing it as an "evolving health threat." But experts say the U.S. outbreak is bigger than reported, and CDC is developing a protocol to expand access to the monkeypox vaccine.

Monkeypox: The latest on the outbreak

WHO: Monkeypox is an 'evolving health threat'

Last week, WHO's International Health Regulations Emergency Committee met to determine whether the current monkeypox outbreak should be labeled a Public Health Emergency of International Concern (PHEIC), the highest alert level WHO can issue.

During the meeting, WHO Director-General Tedros Adhanom Ghebreyesus said the committee shared "serious concerns about the scale and speed of the current outbreak," which has now grown to around 3,000 cases in more than 50 countries.

"What makes the current outbreak especially concerning is the rapid, continuing spread into new countries and regions and the risk of further, sustained transmission into vulnerable populations including people that are immunocompromised, pregnant women, and children," Tedros said.

To stop the outbreak from spreading further, the committee said that "coordinated action," including surveillance, contact tracing, and isolation, is needed. However, the committee ultimately reached a consensus that the outbreak did not currently constitute a PHEIC.

Instead, Tedros said the current outbreak is "clearly an evolving health threat" and "requires our collective attention and coordinated action now." According to STAT News, the committee could reconsider its decision in the future depending on several factors, including:

• If cases rapidly increase over the next few weeks
• If cases become more prevalent among certain groups, such as sex workers
• If the virus becomes more transmissible or begins causing more severe illness

US monkeypox outbreak is bigger than reported, experts say

Currently, the United States has reported 244 cases of monkeypox across 25 states and the District of Columbia. However, health experts say cases are likely being undercounted due to testing bottlenecks, obscuring the true extent of the outbreak in the country.

"We have no concept of the scale of monkeypox outbreak in the U.S.," said Joseph Osmundson, a biologist at New York University.

According to Jennifer Nuzzo, an epidemiologist at Brown University, the country's current testing system for monkeypox is limited and ineffective. In particular, it makes it difficult for providers to order monkeypox tests for their patients, since they must first seek permission and instructions from local or state labs.

"That's really the bottleneck that we're worried about," Nuzzo said. "We need to cast a wider net with testing to find infections that we're missing. And that's really hard to do if we make it cumbersome and difficult for health care providers to request a test in the course of their busy days."

To expand testing, the Biden administration last week announced that it authorized commercial laboratories to conduct monkeypox tests in hopes of drastically expanding the country's testing capacity. So far, CDC has shipped test kits to five commercial laboratory companies, including Quest Diagnostics, Sonic Healthcare, Labcorp, Mayo Clinic Laboratories, and Aegis Sciences.

"By dramatically expanding the testing locations throughout the country, we are making it possible for anyone who needs to be tested to do so," said HHS Secretary Xavier Becerra.

In addition, Nuzzo said CDC and local labs need to remove barriers to testing, including making it easier for providers to submit samples to labs that are already conducting testing.

"Time is not on our side here," she added. "Every day we delay, we are missing links in the transmission chain and are allowing this outbreak to grow possibly beyond control."

CDC to consider expanding access to monkeypox vaccine

CDC last week said it is working with several state and local health departments to increase access to the monkeypox vaccines, particularly as the number of cases that cannot be tracked to a specific source continues to grow.

"We are aware that there are jurisdictions with a larger number of cases that are reporting high percentages of contacts that cannot be identified," said Brett Petersen from CDC. "And there are several considering, planning, and even implementing expanded vaccination programs at this time."

For example, New York City last week became the first American jurisdiction to offer the monkeypox vaccine to individuals other than close contacts of infected patients, expanding access to at-risk groups, including men who had sex with multiple or anonymous male partners in the last two weeks.

So far, demand for the vaccine has been high. Less than a day after launching its vaccination initiative, New York City announced it had run out of its supply of the monkeypox vaccine. And on Monday, Washington, D.C announced that within hours of making vaccination appointments available, the city had run out of its monkeypox vaccine as well.

In addition, CDC said it is developing a protocol to expand access to the monkeypox vaccine, which has only been approved for adults so far, to children if necessary. Currently, around 36,000 doses of the Jynneos vaccine, which is the preferred vaccine against monkeypox, are available for use in the U.S. stockpile, and an additional 500,000 doses have been ordered, with 150,000 expected to be delivered in the next few weeks. (Joseph, STAT News, 6/25; Pannett/Timsit, Washington Post, 6/25; Doucleff, "Shots," NPR, 6/25; Carbajal/Gleeson, Becker's Hospital Review, 6/24; Choi, The Hill, 6/27)